Question

A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

a. Reassess the patient and situation.
b. Revise the turning schedule to increase the frequency.
c. Delegate turning to the nursing assistive personnel.
d. Apply medication to the area of skin that is broken down.

Answer 1

When a nurse finds a stage II pressure ulcer despite the turn schedule, the next action is to reassess and possibly revise the turning schedule.

Step-by-step explanation:

When a nurse finds that a patient has a stage II pressure ulcer on the buttocks despite the implemented turn schedule, the next action the nurse should take is to reassess the patient and situation. This involves evaluating factors such as the patient's overall health, mobility, and any other contributing factors to the development of the pressure ulcer. Based on the reassessment, the nurse may then need to revise the turning schedule to increase the frequency or adjust other interventions to prevent further skin breakdown and promote healing. It is important to involve the healthcare team, including physicians, in making the necessary changes to the care plan.